Cost of stroke in Sweden : an incidence estimate

OBJECTIVES: To estimate the excess cost of stroke in Sweden and the potential costs that could be avoided by preventing first-ever strokes. METHODS: We adopted the incidence approach for estimating the present value of both direct and indirect costs. Data on mortality, stroke recurrence, and inpatient care were estimated from a national register of patient data with a four-year follow-up period. To estimate costs for social services, we used survey data on living conditions before stroke onset and at three and at twenty-four months. Costs for outpatient visits, rehabilitation, drugs, and production losses due to premature death and early retirement were estimated on the basis of both published and nonpublished sources. Lifetime costs were based on life tables adjusted for excess mortality of stroke, and costs in year 4 were extrapolated to subsequent years. RESULTS: The present value direct cost for an average stroke patient is SEK 513,800 (USdollars 56,024 or Euro 60,825). The corresponding indirect cost is SEK 125,110 (USdollars 13,640 or Euro 14,810). Almost 45 percent of the direct costs were attributable to social services. Women had higher costs than men, and costs for survivors increased with age due to social services. CONCLUSIONS: With an incidence of 213 first-ever strokes per 100,000 individuals, the total excess direct and indirect cost of stroke would be SEK 12.3 billion (approximately US$ 1.3 billion or Euro 1.5 billion). Hence, there are large potential cost offsets both in the health-care sector and in the social service sector if the incidence of first-ever stroke could be reduced

Comparison of cardiovascular risk factors and survival in patients with ischemic or hemorrhagic stroke.

BACKGROUND: Differences in risk factor profiles between patients with ischemic and hemorrhagic stroke may have an impact on subsequent mortality. AIM: To explore cardiovascular disease risk factors, including the CHADS(2) score, with survival after ischemic or hemorrhagic stroke. METHODS: Between 2001 and 2005, 87 111 (83%) ischemic stroke, 12 497 (12%) hemorrhagic stroke, and 5435 (5%) patients with unspecified stroke were identified in the Swedish Stroke Register. Data on gender, age, and cardiovascular disease risk factors were linked to the Swedish Hospital Discharge and Cause of Death Registers. Adjusted odds and hazard ratios and 95% confidence interval were calculated using logistic and Cox proportional hazard regression models. RESULTS: Hemorrhagic stroke patients were younger than ischemic stroke patients. All cardiovascular disease risk factors studied, alone or combined in the CHADS(2) score, were associated with higher odds ratios for ischemic stroke vs. hemorrhagic stroke. Higher CHADS(2) scores and all studied risk factors except hypertension were associated with higher odds ratio for death by ischemic stroke than hemorrhagic stroke. Ischemic stroke was associated with lower early mortality (within 30 days) vs. hemorrhagic stroke (hazard ratio = 0·28, confidence interval 0·27 to 0·29). CONCLUSIONS: Patients with hemorrhagic stroke had a higher risk of dying within the first 30 days after stroke, but the risk of death was similar in the two groups after one-month. Hypertension was the only cardiovascular disease risk factor associated with an increased mortality rate for hemorrhagic stroke as compared to ischemic stroke

Sex Differences in Stroke Care and Outcome in the Swedish National Quality Register for Stroke Care.

BACKGROUND AND PURPOSE: Previous reports concerning sex-related differences in stroke management and outcome are inconsistent and are sometimes difficult to interpret. We used data from a national stroke register to further explore possible differences between men and women in baseline characteristics, stroke treatment, and outcome. METHODS: This study included 24 633 stroke events registered in Riks-Stroke, the Swedish national quality register for stroke care, during 2006. Information on background variables and treatment was collected during the hospital stay. After 3 months, the patients' living situation and outcome were assessed. RESULTS: Women were older than men when they had their stroke (mean age, 78.4 versus 73.6 years; P<0.001). On admission to the hospital, women were more often unconscious. Among conscious patients, there was no sex-related difference in the use of stroke unit care. Men and women had equal probability to receive thrombolysis and oral anticoagulants. Women were more likely to develop deep venous thromboses and fractures, whereas men were more likely to develop pneumonia during their hospital stay. Women had a lower 3-month survival, a difference that was associated with higher age and impaired level of consciousness on admission. Women were less often living at home at the 3-month follow-up. However, the difference in residency was not present in patients <85 years who were living at home without community support before the stroke. CONCLUSIONS: Reported sex differences in stroke care and outcome were mainly explained by the women's higher age and lower level of consciousness on admission

Assessment of Functional Outcome in a National Quality Register for Acute Stroke. Can Simple Self-Reported Items Be Transformed Into the modified Rankin Scale?

Background and Purpose-To enable self-reporting of functional outcome in quality registers, the corresponding questions have to be easy to interpret. In scientific research, the modified Rankin Scale (mRS) is a standard assessment method. Such methods, with an outsider observer, are not feasible to use in quality registers. For several aspects, eg, comparisons between outcome in clinical studies and observational studies, we determined to see whether the functional outcome, as assessed in a quality register, can be transformed into mRS grades. Methods-The agreement between self-reported functional outcome (including dependency, living situation, mobility, dressing and toileting) and mRS were analyzed using 555 stroke patients registered in Riks-Stroke, the Swedish quality register for acute stroke, during a 5-month period in 4 hospitals. The self-reported outcome and the mRS grades were concurrently assessed by a telephone interview performed by an experienced nurse 3 months after stroke. Results-A translation using 5 of the questions from Riks-Stroke classified 76% of the patients to the correct mRS grade. The correlation between Riks-Stroke and mRS was 0.821 and Cohen's kappa (weighted) was 0.853. Conclusion-The study shows that self-reported functional outcome can be transformed into mRS grades with a high precision, making the translation useful for future comparative purposes in stroke outcome studies

First-Ever Atrial Fibrillation Documented After Hemorrhagic or Ischemic Stroke: The Role of the CHADS(2) Score at the Time of Stroke.

BACKGROUND: The CHADS(2) score (C, congestive heart failure [CHF]; H, hypertension [HT]; A, age ≥75 y; D, diabetes mellitus; S(2) , prior stroke or transient ischemic attack) is used to assess the risk of ischemic stroke in patients with atrial fibrillation (AF). However, its role in patients without documented AF is not well explored. HYPOTHESIS: The goal of the current study was to explore if the incidence of hospitalization with first-ever AF after stroke increased with increasing CHADS(2) score. METHODS: We identified 57636 patients with nonfatal stroke and no documented AF in the Swedish Stroke Register (Riks-Stroke) during 2001-2004 and followed them for a mean of 2.2 years through record linkage to the Inpatient and Cause of Death registers. Cox regression hazard models were used to estimate the relative risk (RR) of new AF following stroke and its association with different CHADS(2) scores. RESULTS: Overall, 2769 patients were hospitalized with new AF (4.8%, 21.7 per 1000 person-years). The incidence increased from 9.6 per 1000 person-years in CHADS(2) score 0 to 42.7 in CHADS(2) score 6, conferring a RR of 4.2 (95% confidence interval [CI]: 2.5-6.8). For CHADS(2) scores 3-5, the RRs were approximately 3 (vs CHADS(2) score 0). Adjusted RRs were 1.9 (95% CI: 1.7-2.1) for CHF, 1.4 (95% CI: 1.3-1.5) for HT, 2.1 (95% CI: 2.0-2.3) for age ≥75 years, 0.9 (95% CI: 0.8-1.0) for diabetes, and 1.0 (95% CI: 0.91-1.07) for previous stroke. The risk of AF was higher in ischemic than in hemorrhagic stroke. CONCLUSIONS: In this retrospective register study, the incidence of AF following stroke was strongly influenced by higher CHADS(2) scores where age ≥75 years, CHF, and HT were the contributing CHADS(2) components. © 2011 Wiley Periodicals, Inc. Riks-Stroke is funded by the National Board of Health and Welfare and the Swedish Association of Local Authorities and Regions. S. Åsberg has received a research scholarship from the National Association for Stroke Patients in Sweden. All authors have independent affiliations with universities in Sweden. B. Farahmand and K. Henriksson are employees of AstraZeneca R&D, Sweden. A. Terént has received funding from AstraZeneca. N. Edvardsson serves as medical advisor to AstraZeneca R&D, Sweden. The authors have no other funding, financial relationships, or conflicts of interest to disclose

Survival after stroke - The impact of CHADS(2) score and atrial fibrillation.

OBJECTIVE: This study examined all-cause mortality in stroke patients with and without documented atrial fibrillation (AF), and the impact of CHADS(2) score. DESIGN: A cohort of 105,074 patients, 31,821 (30.3%) with and 73,253 (69.7%) without documented AF, was studied. These patients were registered in the Swedish Stroke Registry during the years 2001-2005. Mortality data were retrieved from the Swedish Cause of Death Register. CHADS(2) score prior to stroke were assessed using the Swedish National Discharge Register. RESULTS: The age and sex adjusted relative risk (RR) of death was 1.46 (1.43-1.49) for AF vs non-AF patients. High age (>/=75 years) tripled the risk of death and was the single most important predictor, followed by congestive heart failure, previous stroke and diabetes. Less than half of the AF patients with a CHADS(2) score of 1-6 survived more than 5 years, whereas AF patients with a CHADS(2) score of 0 had a 73% chance of survival. In patients with AF, the relative risk of death was 6.05 (CI: 2.26-6.95); in subjects with the highest vs the lowest CHADS(2) score; the corresponding RR for non-AF patients was 7.93 (CI: 7.01-8.97). CONCLUSIONS: The CHADS(2) score seems to have an impact on all-cause mortality after stroke. The CHADS(2) score can give valuable insight for other outcome variables apart from having had an ischemic stroke and can be applied to patients with different risk factor profiles, e.g. with a previous known cardiovascular disease but without known AF

Timing of oral anticoagulant therapy in acute ischemic stroke with atrial fibrillation : Study protocol for a registry-based randomised controlled trial

Background: Oral anticoagulation therapy is recommended for the prevention of recurrent ischemic stroke in patients with atrial fibrillation (AF). Current guidelines do not provide evidence-based recommendations on optimal time-point to start anticoagulation therapy after an acute ischemic stroke. Non-vitamin K antagonist oral anticoagulants (NOACs) may offer advantages compared to warfarin because of faster and more predictable onset of action and potentially a lower risk of intracerebral haemorrhage also in the acute phase after an ischemic stroke. The TIMING study aims to establish the efficacy and safety of early vs delayed initiation of NOACs in patients with acute ischemic stroke and AF. Methods/Design: The TIMING study is a national, investigator-led, registry-based, multicentre, open-label, randomised controlled study. The Swedish Stroke Register is used for enrolment, randomisation and follow-up of 3000 patients, who are randomised (1:1) within 72 h from ischemic stroke onset to either early (≤ 4 days) or delayed (≥ 5-10 days) start of NOAC therapy. The primary outcome is the composite of recurrent ischemic stroke, symptomatic intracerebral haemorrhage, or all-cause mortality within 90 days after randomisation. Secondary outcomes include: individual components of the primary outcome at 90 and 365 days; major haemorrhagic events; functional outcome by the modified Rankin Scale at 90 days; and health economics. In an optional biomarker sub-study, blood samples will be collected after randomisation from approximately half of the patients for central analysis of cardiovascular biomarkers after study completion. The study is funded by the Swedish Medical Research Council. Enrolment of patients started in April 2017. Conclusion: The TIMING study addresses the ongoing clinical dilemma of when to start NOAC after an acute ischemic stroke in patients with AF. By the inclusion of a randomisation module within the Swedish Stroke Register, the advantages of a prospective randomised study design are combined with the strengths of a national clinical quality register in allowing simplified enrolment and follow-up of study patients. In addition, the register adds the possibility of directly assessing the external validity of the study findings. Trial registration: ClinicalTrials.gov, NCT02961348. Registered on 8 November 2016